Authored by Saeed Shoja Shafti
Introduction: Suicidal behaviour is
seen in the context of a variety of mental disorders and while many
believe that, in general, first episode
psychosis is a particularly high-risk period for suicide, no general
agreement regarding higher prevalence of suicide in first episode
psychosis is
achievable. In the present study, suicides and suicide attempts among
psychiatric in-patients has been evaluated to assess the general profile
of
suicidal behaviour among native psychiatric inpatients and probing any
relationship between serum cholesterol level and suicidal behaviour.
Methods: Five acute academic wards, which have been
specified for admission of first episode adult psychiatric patients, and
five acute nonacademic
wards, which have been specified for admission of recurrent episode
adult psychiatric patients, had been selected for current study. All
inpatients with suicidal behaviour (successful suicide and attempted
suicide, in total), during the last five years (2013-2018), had been
included in
the present investigation. Also, assessment of serum lipids, including
triglyceride, cholesterol, low density lipoprotein and high-density
lipoprotein,
had been accomplished, for comparing the suicidal subjects with
non-suicidal ones.
Results: Among 19160 psychiatric patients hospitalized in razi
psychiatric hospital during a sixty months period, 63 suicidal
behaviours,
including one successful suicide and sixty-two suicide attempts, had
been recorded by the safety board of hospital. The most frequent mental
illness
was bipolar I disorder, which was significantly more prevalent in
comparison with other mental disorders (p<0.04, p<0.02,
p<0.007, and p<0.003 in
comparison with schizophrenia, depression, personality disorders and
substance abuse, respectively). Self-mutilation, self-poisoning and
hanging
were the preferred methods of suicide among 61.11%, 19.44% and 19.44% of
cases, respectively. In addition, no significant difference was evident
between the first admission and recurrent admission inpatients, totally
and separately, particularly with respect to psychotic disorders.
Besides,
with respect to different components of serum lipids, no specific or
significant pattern was evident.
Conclusion: While in the present study the suicidal behaviour
was significantly more evident in bipolar disorder in comparison with
other
psychotic or no-psychotic disorders, no significant difference was
evident between first admission and recurrent admission psychiatric
inpatients.
Moreover, no significant relationship between suicidal behaviour and
serum lipids was palpable.
Suicide is derived from the Latin word for “self-murder” It is a
fatal act that represents the person’s wish to die. A suicide attempt
is a behaviour that the individual has undertaken with at least some
intent to die. The behaviour might or might not lead to death, injury
or serious medical consequences. Several factors can influence
the medical consequences of the suicide attempt, including poor
planning, lack of knowledge about the lethality of the method
chosen, low intentionality or ambivalence, or chance intervention
by others after the behaviour has been initiated [1]. Determining
the degree of intent can be challenging. Individuals might not
acknowledge intent, especially in situations where doing so could
result in hospitalization or cause distress to loved ones.
Markers of risk include degree of planning, including selection of
a time and place to minimize rescue or interruption; the individual’s
mental state at the time of the behaviour, with acute agitation
being especially concerning; recent discharge from inpatient care;
or recent discontinuation of a mood stabilizer such as lithium or
an antipsychotic such as clozapine in the case of schizophrenia.
Approximately 25%-30% of persons who attempt suicide will go
on to make more attempts. Suicidal behaviour is seen in the context
of a variety of mental disorders, most commonly bipolar disorder,
major depressive disorder, schizophrenia, schizoaffective disorder,
anxiety disorders, substance use disorders, borderline personality
disorder, antisocial personality disorder, eating disorders, and
adjustment disorders. It is rarely manifested by individuals with
no discernible pathology, unless in specific circumstances, like
medical, political, or religious conflicts [1].
According to the findings of a study, among male psychiatric
population, the absolute risk of suicide was highest for bipolar
disorder, followed by unipolar affective disorder and schizophrenia.
Among female psychiatric population, as well, the highest risk was
found among women with schizophrenia, followed by bipolar
disorder [2]. According to data, approximately 5%-6% of individuals
with schizophrenia die by suicide, about 20% attempt suicide on
one or more occasions, and many more have significant suicidal
ideation. Suicidal behaviour is sometimes in response to command
hallucinations to harm oneself or others. Suicide risk remains high
over the whole lifespan for males and females, although it may be
especially high for younger males with comorbid substance use.
Other risk factors include having depressive symptoms or feelings
of hopelessness and being unemployed and the risk is higher, also,
in the period after a psychotic episode or hospital discharge [3].
It is interesting that Bleuler had drawn clinicians’ attention
that the most serious of the schizophrenic symptoms is the
suicidal drive. [4]. Up to 50 percent of suicides among patients
with schizophrenia occur during the first few weeks and months
after discharge from a hospital; only a minority commit suicide
while inpatients [3]. Having three or four hospitalizations during
their 20s probably undermines the social, occupational, and sexual
adjustment of possibly suicidal patients with schizophrenia.
Consequently, potential suicide victims are likely to be male,
unmarried, unemployed, socially isolated, and living alone-perhaps
in a single room. After discharge from their last hospitalization, they
may experience a new adversity or return to ongoing difficulties. As
a result, they become dejected, experience feelings of helplessness
and hopelessness, reach a depressed state, and have, and eventually
act on, suicidal ideas. [5].
Abrupt discontinuation of medication, poor treatment
compliance, social isolation, and increased expectation of good
performance from others and from patients themselves, are risk
factors for suicide in schizophrenics [6]. Also, the lifetime risk
of suicide in individuals with bipolar disorder is estimated to be
at least 15 times that of the general population. In fact, bipolar
disorder may account for one-quarter of all completed suicides
[7]. Many believe that, in general, first episode psychosis (FEP) is
a particularly high-risk period for suicide, in which risk elevates by
60% within a first year of treatment as compared to later stages
of illness. In this regard, longer duration of untreated psychosis,
greater symptoms of depression, and positive symptoms of
psychosis were found to increase the odds of experiencing suicidal
ideation [8].
While according to some studies depressive symptoms during
the index psychotic episode and comorbidity with stimulant abuse
at baseline were relevant predictive factors for suicidal behaviour
during the first years of first affective and non-affective psychotic
episodes [9], more depressive symptoms, higher insight, and
negative beliefs about psychosis increase the risk for suicidality in
FEP [10]. Impulsive behaviour such as self-harm, as well as having
a family history of severe mental disorder or substance use, have
been stated as important risk factors for suicide in FEP [11,12].
Furthermore, low levels of cholesterol have been described in
suicide behaviour including among those individuals who have an
increased tendency for impulsivity [13,14].
While, as a kind of psychological explanation, some scholars
believe that young men in the early stages of their treatment are
seeking to find meaning for frightening, intrusive experiences with
origins which often precede psychosis, and these experiences invade
personal identity, interactions and recovery [15], some suggests
that personality characters, specifically, passive-dependent traits
can be a predictor of first suicide attempts FEP [16]. On the other
hand, no general agreement regarding higher prevalence of suicide
in FEP is so far achievable. For example, while researchers like
[2,8,17,18] have stated that FEP is a particularly high-risk period
for suicide, with a risk as high as 10-60% during the first year of
treatment, other scholars like [19-22] have expected a lower risk
or stated that suicide rates are difficult to measure in FEP patients,
even in carefully defined samples. In the present study, suicides
and suicide attempts among psychiatric in-patients, during the
last five years, in Razi psychiatric hospital, as the largest national
psychiatric hospital in Iran and region, has been evaluated to assess
the general profile of suicidal behaviour among native psychiatric
inpatients, comparing first admission with recurrent admission
patients, and probing any relationship between serum cholesterol
level and suicidal behaviour.
Razi psychiatric hospital in south of capital city of Tehran, as
one of the largest and oldest public psychiatric hospitals in the
Middle East, which has been established formally in 1917 and with
a capacity around 1375 active beds, had been selected as the field of
study in the present retrospective assessment. Amongst its separate
existent sections, five acute academic wards, which have been
specified for admission of first episode adult psychiatric patients,
and five acute non-academic wards, which have been specified for
admission of recurrent episode adult psychiatric patients, with a
collective capacity around two hundred active beds in each cluster
(four hundreds beds, totally), had been selected for current study.
Among the aforesaid academic divisions, two wards included
female inpatients, with around eighty beds, and the remaining
three wards included male inpatients.
All non-academic wards involved male inpatients. For valuation,
all inpatients with suicidal behaviour (successful suicide and
attempted suicide, in total), during the last sixty months, had been
included in the present investigation. Besides, clinical diagnosis was
based on Diagnostic and Statistical Manual of Mental Disorders, 5th
edition (DSM-5) [23]. Also, assessment of serum lipids, including
triglyceride (TG), cholesterol, low density lipoprotein (LDL)
and high density lipoprotein (HDL), which was part of routine
laboratory checkups for all patients upon admission, whether for
the first time or periodically, had been accomplished, for comparing
the suicidal subjects with non-suicidal ones, incidentally.
Statistical analyses
While ‘t-test’ has been used for comparison of means as regards
mean total level of serum lipids, difference of suicidal behaviour
between first admission and recurrent admission patients, had been
analyzed by ‘comparison of proportions. Statistical significance as
well, had been defined as p value ≤0.05. MedCalc Statistical Software
version 15.2 was used as statistical software tool for analysis.
As said by the results, among 19160 psychiatric patients
hospitalized in razi psychiatric hospital, during a sixty months
period (2013-2018), sixty-three suicidal behaviours, including
one successful suicide and sixty-two suicide attempts, had been
recorded by the security board of hospital (Table 1). Thirtythree
of patients were male and thirty of them were female,
with no significant difference about quantity (Table 2). The most
frequent mental illness was bipolar I disorder (34.92%), which
was significantly more prevalent in comparison with other mental
disorders (p<0.04, p<0.02, p<0.007, and p<0.003 in comparison
with schizophrenia, depression, personality disorders and
substance abuse, respectively).
The other disorders included schizophrenia (19.04%), major
depressive disorder (MDD) (17.46%), personality disorders
(borderline & antisocial) (14.28%), substance abuse disorders,
especially methamphetamine induced psychosis (MIP) (12.69%),
and adjustment disorder (1.58%) (Table 3) (Figure1). Also, no
significant difference was evident between the first admission and
recurrent admission inpatients, totally (p<0.31) and separately,
particularly with respect to psychotic disorders (Table 3) (Figure
2). The annual incidences of suicidal behaviour in both groups
were comparable, and they were around 0.035% and 0.030%, in
first admission and recurrent admission psychiatric inpatients,
respectively (Table 1). While self-mutilation, self-poisoning and
hanging were the preferred methods of suicide among 61.11%,
19.44% and 19.44% of cases, respectively, the first style was
significantly more prevalent than the other ways (Z=1.96, P<0.059,
CI: -0.0088,0.4532). Furthermore, no significant gender-based
difference was evident with respect to the style of suicide in the
present assessment (Figure 3). Besides, with respect to different
components of serum lipids, no specific or significant pattern was
evident, except that all hypolipidemic patients (n=7) were diagnosed
as major depressive disorder, while 80% of hyperlipidemic patients
(n=5) were diagnosed as bipolar I disorder (Table 4).
Always in psychiatry, when giving information about the
diagnosis, course of illness, and treatment, the therapist should
not ignore the risk of suicide [1]. Also, there is a high proportion
of young people with first-episode psychosis who attempted
suicide before their first contact with mental health services. This
finding suggests that the mortality rates associated with psychotic
disorders may be underreported because of suicide deaths taking
place before first treatment contact [24]. It should constantly be
considered that in the psychiatric hospital setting the inpatient at
risk for suicide has previously exhibited suicidal behaviour, suffers
from schizophrenia, was admitted involuntarily, and lives alone
[24].
It is interesting that among persons hospitalized, the risk of
suicide was greater in 1985-1991 than in 1995-2001 for post
discharge period, particularly for patients with schizophrenia and
patients with affective disorders. Thus, not only the restructuring
and downsizing of mental health services was not associated with
any increase in suicides, the risk of suicides decreased significantly
between the two time periods among several diagnostic categories.
But, while in terms of post-discharge suicides, the downsizing of
psychiatric hospitals has been a success, there is still a substantial
need for better recognition of suicidal risk among psychiatric
patients [25].
According to a survey, there are 2 sharp peaks of risk for suicide
around psychiatric hospitalization, one in the first week after
admission and another in the first week after discharge; suicide
risk is significantly higher in patients who received less than the
median duration of hospital treatment; affective disorders have
the strongest impact on suicide risk in terms of its effect size and
population attributable risk; and suicide risk associated with
affective and schizophrenia spectrum disorders declines quickly
after treatment and recovery, while the risk associated with
substance abuse disorders declines relatively slower [26].
The accessibility to one or more means of suicide is a recognized
factor in psychiatric institutions. The same is true for the conditions
of care: inadequate supervision, the underestimation of the risk of
suicide by teams, poor communication within the teams and the
lack of intensive care unit promote suicide risk [27]. But according
to another study in FEP, most attempts occurred when patients
were treated as outpatients and were in regular contact with
the service [17]. As suicide is a relatively rare event in psychotic
disorders, general population-based prevention strategies may
have more impact in this vulnerable group as well as the wider
population [28,29].
While the immediate post-discharge period is a time of marked
risk, rates of suicide remain high for many years after discharge and
patients admitted because of suicidal ideas or behaviours and those
in the first months after discharge should be a focus of concern
[30]. Back to our discussion and according to the findings of the
present study, The most common principal diagnoses among the
suicide subjects were bipolar I disorder and schizophrenia, which
was similar to the findings [2], except that no gender difference
regarding prevalence of these disorders among male and female
patients was repeatable here.
But, our findings were not in complete agreement with the
conclusion of Thong JY et al., who had found only schizophrenia and
depression as the most common principal diagnoses among their
suicide subjects [31] and Roy et al., who had declared schizophrenia
as the major diagnosis among suicide victims [24]. Meanwhile other
psychiatric disorders, like personality disorders and substance
abuse disorders, in addition to the diagnoses, had been designated
in the present study, as remarkable diagnoses among suicide
subjects; though fewer than the aforementioned diagnoses. The
higher prevalence of bipolar disorder in the present assessment is
likewise comparable to the outcomes of a further study regarding
suicidal behaviour among Iranian inpatient youngsters [32].
In the same way, the higher incidence of self-mutilation, as the
preferred method of suicide in the present evaluation, was parallel
to the said study, except than its significantly higher prevalence
amongst female adolescents [33]. Also, in keeping with the results,
while the annual incidences of suicidal behaviour in both groups
were comparable, they were lower than assessments [11,34], and
higher than approximations [35], which could be stemmed from
cultural, instrumental, diagnostic and methodical differences. Also,
in accordance with the outcomes of the present assessment, no
significant difference was evident between the first admission and
recurrent admission inpatients, totally and separately, particularly
with respect to psychotic disorders.
Such an outcome is clearly incongruous with the findings
[2,8,17,18] who have stated that first episode psychosis is a
particularly high-risk period for suicide and first-episode psychotic
disorder , in general, has seemed to be a high-risk population for
suicidal behaviour during the first year of treatment. On the other
hand, our findings are compatible with the stances [19-22], who
have estimated a lower risk or indicated that suicide rates are
difficult to measure in FEP patients, and there is relatively little
specific information about the risk of suicide at illness onset or
retrospectively concerning the untreated psychotic period.
Above and beyond, with respect to relationship between serum
lipids and suicidal behaviour, outcome of the present assessment
was not in harmony with the findings [13, 14], because while
there was a couple of patients with higher or lower serum level
of cholesterol, triglyceride, LDL and HD, no specific or significant
pattern was evident in this regard; so, it seems that maybe such
a difference was associated more to alteration of appetite, as a
secondary phenomenon, rather than core variation of metabolism,
as a primary etiologic issue. Anyhow, disregard to outcomes of the
present study and its similarities or differences with comparable
studies, elements of an inclusive prevention policy can be grouped
under five items: securing the hospital environment, optimization of
the care of the patients at suicidal risk, training of the medical teams
in the detection of the risk and in the care of the suicidal subjects,
involvement of the families in the care and implementation of postevent
procedures following a completed suicide or an attempt [36].
Also, to reduce the number of suicide attempts among
individuals treated for FEP, psychiatric services could consider:
restricting the amount of medication prescribed per purchase;
individualized suicide risk management plans for all newly admitted
patients, including those who do not appear to be at risk; stringent
reviews of inpatient psychiatric units for potential ligature points;
providing information and psycho-education for significant others
in recognition and response to suicide risk; fostering patients’
problem solving and conflict resolution skills; and regular risk
assessment and close monitoring of patients, particularly during
the high risk period of 3 months after a suicide attempt [17].
Also, along with enhancement of insight, coping strategies should
be boosted with a goal of minimizing depression and preventing
suicidality [37].
Absence of post- discharge following program, deficiency of
documented data regarding the suicidal behaviour or its idea before
admission, allocating wards to academic and non-academic, which
could impact the quality of care, lack of female gender in the nonacademic
wards for making it more similar to the academic wards,
which included an equal mixture of male and female inpatients,
were among the weaknesses of the present assessment. In spite
of remarkable findings of the current study, more methodical and
comprehensive investigations in future, with taking into account
the above shortages, can improve the quality and amendment of
mental health services for proper response to patients’ unavoidable
problems.
While in the present study the suicidal behaviour was
significantly more evident in bipolar disorder in comparison with
other psychotic or no-psychotic disorders, no significant difference
was evident between first admission and recurrent admission
psychiatric inpatients. Moreover, no significant relationship
between suicidal behaviour and serum lipids was palpable.
None.
No conflict of Interest.
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